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We continually update our website so that it works best with the newer versions of “standard” browsers.

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On the next page you’ll be asked to provide the amount you wish to pay as well as
select the Plan to which your payment should apply. If you wish to pay premiums for
multiple plans, you’ll need to repeat the process for each plan.

Forms Center

For your convenience, you can download and print forms online. Instructions for completing and submitting your request
are provided on each form. Most forms require your signature, and some will require follow-up communication or paperwork.

If you have questions, contact us at 800-568-2001
or ada@greatwest.com for assistance.

Dentists: The information on this website is not a contract. Benefits are provided through a Group Policy Nos. (104TLP Term Life,
1105GDH-IPP Disability Income Protection, 1106GDH-OEP Office Overhead Expense Disability, 104GUL Universal Life, 104LTLP Level Term Life,
1117GH-HIP Hospital Indemnity, 1127GH-CIP Critical Illness, and 1107GH-MCP MedCASHSM) filed in the State of Illinois in accordance with
and governed by Illinois law, issued to the American Dental Association by Great-West Financial®. The ADA is entitled to receive royalties
from the ADA Members Insurance Plans. Coverage is available to all eligible ADA members in all fifty states and U.S.
territories under the aforementioned group policy. Each Plan participant will receive a Certificate of Insurance explaining the terms and
conditions of the policy. Level Term Life premiums are fixed based on the selected duration of 10 or 20 years. An insured must maintain ADA membership
throughout selected term to remain eligible for insurance. Annually Renewable Term Life, Hospital Indemnity, Critical Illness, and MedCASH premiums increase annually
based on age. Recommended premiums under the Term Plus® Universal Life plan consist of the cost of insurance (which may vary based on
the member’s age and coverage amount), the amount chosen by the member for deposit into his/her Policy Value Account and a service
charge. Premium deposits may fluctuate or remain level depending upon the amount maintained in the Policy Value Account. Disability
Income Protection premiums increase every 5 years and Office Overhead Expense every 10 years based on age. Premium credit for Annually
Renewable Term Life and Term Plus Universal Life is not guaranteed but reevaluated annually. Premium credit for Disability Income Protection,
Office Overhead Expense, Hospital Indemnity, Critical Illness, and MedCASH is not guaranteed but reevaluated semi-annually.

Dental Students: The information on this website is not a contract. Student coverage is issued regardless of your condition if you are under 45.
If you are 45 or older, you can apply for the no-cost coverage and all student program features by providing proof of good health.
Coverage renews automatically each academic year. Individuals may convert coverage to the plans for practicing dentists after
graduation by paying ADA member premiums and maintaining ADA membership. Benefits are not payable, as defined by the respective policy,
for death or disability resulting from a sickness, disorder, physical condition, or symptom that existed or was treated within
12 months prior to enrollment. Benefits are provided through a group policy Nos. (104TLP Term Life and 1108GDH-SDP Student Disability)
filed in the State of Illinois in accordance with and governed by Illinois law, issued to the American Dental Association by
Great-West Financial®. Coverage is available to eligible ADA members in all fifty states and
US territories under the aforementioned group policy. Each insured will receive a certificate of insurance explaining the terms and
conditions of the policy.

ADA® is a registered trademark of the American Dental Association and Great-West Financial® is a registered
trademark of GWL&A.

Ever wonder why so many ADA members, student members and their families choose ADA members insurance plans? Sign up for our email communications to get answers and information about ADA members insurance plans.

Email

ADA Identification No.

ADA Number is 9 digits or T followed by 8 digits if your number is temporary

X

ADA Number is 9 digits or T followed by 8 digits if your number is temporary